Terapia percutânea versus cirurgia para Insuficiência Mitral Secundária: Uma revisão sistemática e meta-análise

Abstract

Until 2018, surgery was the only therapy capable of promoting improvement in patients with severe secondary mitral regurgitation with left ventricular ejection fraction below 30%, despite low survival. However, that year, the COAPT Trial study concluded a reduction in mortality and symptoms in one year for patients with this valvular heart disease who underwent percutaneous therapy using the MitraClip, with an ejection fraction of 20 to 50% and a median of 30%. As a result, many questions about the equivalence between surgery and MitraClip were raised because the COAPT Trial did not compare percutaneous therapy directly with surgery, demonstrating the superiority of MitraClip only over conservative therapy. Therefore, this study aimed to compare the effectiveness and complications between surgery and percutaneous therapy in patients with secondary mitral regurgitation to indicate which therapy is best according to left ventricular ejection fraction, surgical risk and age. To this end, a systematic review and meta-analysis of randomized clinical trials and cohort studies was carried out. The studies reviewed were published from January 2000 to August 2022. The databases searched were MEDLINE, EMBASE, google scholar, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews. Only studies comparing postoperative outcomes between surgery and MitraClip for functional mitral regurgitation were included. All selected studies were cohort studies and randomized clinical trials. Only studies in which the population had an average Logistic Euroscore greater than 5% were included. The variables studied were moderate to severe residual mitral regurgitation, heart failure classes III and IV, mortality within 30 days or 1 year after, occurrence of neurological accidents, sepsis and serious adverse effects with referral to the critical emergency department within 30 days after the surgery. As a result, the study was able to see that percutaneous therapy can still present a significant reduction in mortality compared to surgery. Furthermore, it was shown that the effectiveness of surgery in reducing residual regurgitation is related to surgical risk, left ventricular ejection fraction and age.